Secure Loan Application Form

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:

you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI)

your spouse will use the account, or

you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance, complete the Other section to the extent possible about the person on whose payments you are relying.

Joint Credit: Each Applicant must individually complete the appropriate section below, If Co-Borrower is spouse of the Applicant,- mark the Co-Applicant box.

Guarantor: Complete the Other section if you are a guarantor on an account/loan.

Check below to indicate the type of account(s) and type of credit for which you are applying. Married Applicants may apply for a separate account.

Are you applying for individual or joint credit ?: Individual
Joint

Type:

Amount Requested:

$
.00

Loan Purpose:

Payment Protection Coverage

Check coverage(s) desired. The Credit Union will disclose the cost of this voluntary insurance to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.

Single Credit Disability
None

Single Credit Life Insurance
Joint Credit Life Insurance
None

Applicant Information

Applicant's Name:

Account #:

Driver License #:

Social Security #:

Email:

US Citizen:

Yes
No

Birthdate:

Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:

Marital Status:

Home Phone #:

Cell Phone #:

Street Address:

City:

State:

Zip #:

Current Address since:

(MM/YY)

If less than 3 yrs enter previous address:

Joint Applicant's Name:

Account #:

Driver License #:

Social Security #:

Email:

US Citizen:

Yes
No

Birthdate:

Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:

Marital Status:

Home Phone #:

Cell Phone #:

Street Address:

City:

State:

Zip #:

Current Address since:

(MM/YY)

If less than 3 yrs enter previous address:

Employment Information

Applicant Employer's Name:

Employer Phone #:

Employer Address:

Position:

Date Hired (MM/DD/YY):

Monthly Gross Income ($):

Other Income ($):

per Month

Complete if current employment is less than 2 years:
Previous Employers Name:

Yrs Employed:

Joint App. Employer's Name:

Employer Phone #:

Employer Address:

Position:

Date Hired (MM/DD/YY):

Monthly Gross Income ($):

Other Income ($):

per Month

Complete if current employment is less than 2 years:
Previous Employers Name:

Yrs Employed:

NOTE: Alimony, child support, or separate maintenance
income need not be revealed if You do not choose to have it considered
as a basis for this credit request.

Debts & Assets

Lender

Type

Balance

Min. Pmt.

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

$
.00

Child Support Payments / Alimony

$

Assets:

Description:

Value:

Description:

Value:

Have you ever filed for bankruptcy or had debt adjustment under Chapter 13?

Are you a party in a lawsuit?

Have you ever had property foreclosed or repossesion in the last 7 years?

Is your income likely to decline in the next two years?

Are you co-maker/endorser on any loan not listed above?

If yes then for whom?

If yes then to whom?

References

First Name:

Middle Name:

Last Name:

Suffix:

Home Phone Number:555-555-5555

What is their home address?

Street:

City:

State:

Zip:

What is the relationship?

Contact Method

How would you prefer to be contacted?
Home Phone
Cell Phone
Email

Additional Comments:

Submit Application

State Law NoticesOHIO RESIDENTS ONLY: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law. WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 768.59, or court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

You agree that everything stated in this application
is correct to the best of your knowledge. The Credit Union
is authorized to investigate your creditworthiness, employment
history, and to obtain a credit report and to answer questions
about their credit experience with you. You understand that
any false or misleading statement in your application may
cause any loan or extension of credit to be in default.
You authorize us to accept your facsimile signatures on
this application and agree that your facsimile signature
will have the same legal force and effect as your original
signature. You assume any risk that may be associated with
permitting us to accept your facsimile signature.

By pressing the "Submit Form" button
below, you agree to the above statement. You understand
that we will require your signature on additional documents
prior to disbursing any credit proceeds.